Excellent thought the Microbiologist; they’re being proactive about a serious problem.
“If she’s not allergic to anything then IV Benzylpeniciilin and Clindamycin. Have you looked for retained products and done a DNC?” asked the Microbiologist.
“She’s really unwell, we don’t really want to take her to theatre. We might damage the uterus” replied the Registrar.
“She’s unlikely to improve if you don’t,” said the Microbiologist sympathetically. “You need to remove as much infected material as you can. I know it sounds brutal but it’s really important”.
“Okay,” said the Registrar sounding doubtful, “my Consultant is with the patient at the moment so I’ll go and tell them what you have advised. Thanks for your help.”
The Microbiologist put down the phone and put down his pen. Time to visit the obstetric ward and see what is going on…
What is the cause of puerperal fever?
Puerperal fever is caused by the bacterium Streptococcus pyogenes, also known as the Group A beta-haemolytic streptococcus. The bacterium can be either introduced from the mothers own flora, the attending healthcare professional or even from a contaminated environment. The bacterium then causes inflammation in the genital tract and ascends into the uterus causing what is known as endometritis (inflammation of the uterus).
The history of puerperal fever
Puerperal fever has an important historical context in the world of infection control and microbiology. Back in the 1700s and 1800s puerperal fever was a leading cause of maternal death. Puerperal fever was particularly common in “lying-in wards” (a room where women were confined in childbirth), especially those which were staffed by “accoucheurs” as the Doctors practicing in the “new field of obstetrics” were known; “accoucher” in French means “to give birth”, or to “go into labour”.
In the 1840s, Ignac Semmelweis, a Hungarian doctor working in Vienna, realised the association between Doctors and the higher incidences of puerperal fever. He wasn’t the first to makes these associations but he was the first to realise that the Doctors hands were the route by which the infection was being transmitted. In particular he realised that there was an association between Doctors performing post-mortems, on women who had died of puerperal fever, who then went and examined women in labour without washing their hands. Okay, this is something we would find abhorrent today but back in the 1800s this was normal practice…! I’ve blogged before on the fantastic series Charité, even with its German language and subtitles, which encompasses these events and is well worth watching; I think it’s still available on Netflix!
But it’s what Semmelweis did next that really makes him stand out. He put in place procedures to ensure that all doctors entering the wards washed their hands in a dilute chlorine solution and the effect was dramatic. When he compared the clinic where hand washing was in practice with a clinic where it wasn’t he saw the mortality had dropped from 12% to 3%!
Unfortunately Semmelweis’ story does not have a happy ending. He continued to try and convince people of his ideas with no success. In 1865 he suffered a breakdown and his “colleagues” had him forcefully committed to a “mental institution”. It is thought that he was beaten by guards, put in a strait jacket and locked in a darkened cell. He died 2 weeks later due to sepsis from an injury he sustained, during the scuffle, to his right hand... ironically it was probably the very bacterium he had spent his career trying to control, Streptococcus pyogenes!
Nowadays we refer to Semmelweis as the “Father of Infection Control” because he was the first person to show that close attention to hand hygiene reduces rates of infection. An amazing piece of work and Semmelweis is now rightly recognised for what he did, even if at the time he was treated so badly.
How does puerperal fever present?
Puerperal fever presents with fever during labour or up to 10 days after delivery. It is associated with severe abdominal pain and offensive bloody vaginal discharge. Often patients appear a lot sicker than the clinical findings in the genital tract, with tachycardia, hypotension and sepsis.
Any swabs taken from the vagina or placenta, as well as blood cultures, usually grow S. pyogenes, although endometritis itself can be caused by numerous other bacteria. It is the severity of the presentation that is the usual clue to this being S. pyogenes.
How should puerperal fever be managed?
Puerperal fever due to S. pyogenes is an obstetric emergency. Treatment consists of source control, antibiotics and supportive care with fluids and antipyretics etc.
Source control is the most important aspect of the management of puerperal fever. Patients often have retained products of conception (RPOC); these are bits of placenta still within the uterus. The location and nature of RPOC makes the infection difficult to treat and antibiotics less effective so these RPOC need to be removed, usually in a procedure with the unpleasant name of a dilatation and curettage (DNC). This should be done as soon as possible and can be life-saving.
Infection with S. pyogenes is often severe and requires the antibiotics IV Benzylpenicillin and IV Clindamycin to treat it. I tend to use both together because Benzylpenicillin kills the bacterium and Clindamycin interferes with the bacterium’s ability to produce toxins which makes the combination particularly effective.
Puerperal fever due to S. pyogenes is also an urgently notifiable disease. Public Health England will trace all household members and consider giving antibiotic prophylaxis, or eradication therapy, in order to prevent any further cases of infection caused by this aggressive bacterium, e.g. cellulitis, tonsillitis, septic arthritis and even necrotising fasciitis.
By the time the Microbiologist got to the obstetric ward (in our modern hospital scenario not the 1840’s “lying–in” ward!) the Consultant Obstetrician had already advised the operating theatre team of the need to do an emergency procedure.
With excellent source control, antibiotics and Critical Care support the patient made a full and speedy recovery and was soon back home with her new baby; a relief to all concerned. Fortunately there were no further cases on the obstetric ward but even so everyone continued to pay close attention to washing their hands…
If you’re interested in knowing more about the history of puerperal fever and Semmelweis there’s a nice little, easy to read, book called “The Doctor’s Plague” by Sherwin B. Nuland which is very good.
…I’m off to catch up on Charité season 2!